Fire Claim Form (Page 2 of 2) in pdf

Fire Claim Form Page 2

Who has witnessed the loss?

Please enclose his statement.

What measures were taken to minimize the loss ?

If damage is due to the 'Act of God', then please enclose the

report from the meteorological department / newspaper

cuttings.

Describe the incident.

10.

Has the Public Fire Brigade /Police were informed?

If yes, Please enclose the certificate from the Fire Brigade/

Yes

F.I.R from Police.

11.

Give dates of any previous claims of a similar nature you

D D M M Y Y

have made.

13.

Were there at the time of the occurrence any other existing

Yes

Insurance policies on the said Property, with any other

If Yes, please provide full particulars

Company or Insurer, whether effected by the claimant or by

any other Person ?

Details of Claim for property destroyed or damaged as required by the conditions of the company's policies.

Policy No. &

Description of property

Amt. Insured

Market Value

Amt. Claimed

Item of Policy

claimed for in detail

at time of loss

after the loss

I/We do hereby solemnly and sincerely declare that the details appended hereto, are a full, true and correct statement of the loss, sustained

by me/us on the property insured by the above policy in consequence of the aforesaid loss amounting to the sum of Rs.________________ and

that the amounts claimed in respect of each and all of the several articles or items of property damaged or destroyed, constitute their value at the

time of loss or damage not including profit of any kind.

I/We do hereby solemnly and sincerely declare that I/We have not either directly or indirectly, proximately or remotely caused the said loss,

or by connivance, fraud or misrepresentation sought to benefit thereby, and I/We make the foregoing solemn declarations conscientiously

believing the same to be true, this____________ day of___________________

Address

Signature of the Insured

Fire Claim Form Page 2